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General NPI Number Information
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NPI Number | 1215690227
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Entity Type | Individual
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Provider Name | KESIA DERILUS
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Gender | Female
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Dates
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Enumeration Date | 10/16/2021
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Last Update Date | 10/16/2021
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Provider Practice Location Address
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Address Line | 814 E CAMP WISDOM RD
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City | DUNCANVILLE
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State | TX
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Zip | 75116-2828
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Country | US
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Telephone | 214-217-0303
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Fax |
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Provider Business Mailing Address
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Address Line | 12660 HILLCREST RD APT 6201
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City | DALLAS
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State | TX
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Zip | 75230-2028
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Country | US
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Telephone | 954-560-0951
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2144804
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License Number State | TX
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